Tackling change in mental health service delivery: A qualitative evaluation of a lifestyle program targeting mental health staff – Keeping our Staff in Mind (KoSiM)

Abstract Issues addressed People with severe mental illness have adverse health outcomes compared to the general population. Lifestyle interventions are effective in improving health outcomes in this population. Current cultural processes in mental health services do not generally incorporate physical health care practices. Innovative education is required to improve knowledge and confidence of staff in the delivery of preventative health measures. Methods The Keeping our Staff in Mind (KoSiM) program delivered a brief lifestyle intervention to mental health staff. A qualitative analysis following the Standards for Reporting Qualitative Research was undertaken. Semi‐structured interviews designed to elicit information about the acceptability of the program and the impact of the intervention on participants' personal and professional lives. The interviews were analysed using thematic analysis, with coding independently developed and reviewed by three authors. Results Of the 103 eligible participants, 75 were interviewed. Responses revealed four main themes: (i) positive changes in clinician's approach to physical health care, (ii) improvements in attitudes to self‐care and family wellbeing, (iii) positive changes in workplace culture associated with physical health care delivery and (iv) high levels of acceptability of the program. Conclusion The KoSiM model may be useful in other settings as a means of changing the culture of mental health services to better integrate physical health care as a core part of mental health service provision. So what? A novel approach using staff focussed lifestyle interventions model may cut through the resistance that is encountered when implementing proven methods of clinical intervention where cultural barriers exist.


| INTRODUCTION
People who experience a severe mental illness (SMI) have a 15-year reduction in life expectancy compared to the general population. 1 The majority of deaths are attributable to preventable cardiovascular disease, which are often exacerbated by antipsychotic use. 2 Lifestyle interventions targeting modifiable risk factors including diet and sedentary behaviour are effective in improving physical health outcomes for people who experience a SMI. [3][4][5][6] Social stigma, poverty, social isolation, low educational attainment and poor psychological health often lead to lower levels of engagement and follow-through with general and preventative health services. 7 This increases the importance of mental health services targeting the physical health of people who experience a SMI through screening and lifestyle interventions.
Whilst mental health professionals are ideally placed to provide lifestyle interventions, 8 significant barriers exist to delivering this type of care. Diagnostic overshadowing (attributing physical symptoms to a mental health condition), lack of specialist education, low confidence of staff to deliver interventions, heavy workloads are some of the reasons that mental health organisational cultures that do not embrace physical health care. 9 There have been repeated calls in the literature to increase the amount of physical health training to mental health professionals to improve health care outcomes for those who experience a SMI. Education and training initiatives can have a positive impact on knowledge of physical health issues in SMI, and the confidence and attitudes of mental health professionals to deliver physical health interventions. 10 However, it has been identified that future research should investigate practice change interventions to increase the delivery of physical health intervention and support. 9 A healthy workforce is associated with higher levels of staff retention, lower levels of absenteeism, and overall higher rates of productivity amongst health professionals. 11 However, health professionals often share similar health concerns to the people they treat. 12 Poor lifestyle habits in clinicians can have a direct impact on the quality of care they provide. 13 Physical health interventions for staff have been shown to be feasible and acceptable in mental health settings. 14 Furthermore, some of these interventions have been demonstrated to improve staff morale and their inclination to participate in healthy lifestyle activities. 15 Furthermore, the promotion of healthy lifestyle behaviours by health professionals is more likely to occur when health professionals themselves engage in healthy lifestyle behaviours. 16 The physical health of health care professionals themselves is considered important in the acceptance of lifestyle advice, and when health care professionals follow their own advice. 17 The Keeping the Body in Mind (KBIM) program is a real-world intervention delivered as part of standard care within a public mental health service that demonstrated that weight gain could be prevented in young people commencing antipsychotic treatment. 18 Innovations in health care are more likely to become accepted and become widespread in an organisation if shared values exist and are reinforced by influential team members. 19 To support the scaling-up of the KBIM program to adults who experience SMI, the Keeping our Staff in Mind (KoSiM) program was implemented prior to its launch, as a facilitator for this health care innovation. 20 KoSiM provided an intervention to mental health staff that comprised a brief version of the KBIM lifestyle intervention that people with lived experience of SMI received, creating an experiential learning opportunity. 21 The stated goals of the KoSiM program were improving staff health, instigating culture change regarding the importance of the physical health of people with a lived experience of SMI, and increasing the capability of mental health staff to deliver physical health assessments and interventions.
A full description of the KoSiM program and its quantitative outcomes has been published previously. 21 This report focuses on the qualitative analysis of the KoSiM program, to understand the experiences of staff participants who completed the intervention and comprehend its efficacy and acceptability of its stated goals.

| METHODS
A pragmatic single-arm intervention study was conducted in a public mental health service, including inpatient and community settings, in Sydney, Australia. Participants received a five-session individualised lifestyle intervention (delivered over 5 weeks) that incorporated physical activity and nutritional counselling delivered by multidisciplinary teams.
An initial assessment was provided to participants which incorporated an exercise physiologist, dietitian and clinical nurse consultant, with a plan formulated. Participants then had access to four weekly sessions with their choice of clinician. The aim of this qualitative study was to investigate the experiences of staff participants including the perceived effect on their own wellbeing as well as the impact on their work practices and families. This qualitative study was initiated and designed by the first author (A.W.). All participants were informed about the study by the interviewer and written informed consent was obtained. The study was approved by the South Eastern Sydney Local Health District Human Research Ethics Committee (HREC 15/054).
The reporting of this research follows the Standards for Reporting Qualitative Research, a list of 21 items that support transparent reporting of qualitative research. 22 The sampling approach was to collect data from as many participants as possible who met the inclusion criteria in order to reach data adequacy. 23 Data collection was deemed to be complete when thematic saturation had been reached as determined by three researchers, as indicated by additional data generating minimal or no new knowledge to address the experiences or impact of the intervention on participants. 24  Thematic analysis was utilised for analysing the collected data. Thematic analysis provides precision and consistency and is also an exhaustive process. 27 This approach has been commonly used to examine the impact of lifestyle interventions and provides sufficient detail for the reader to establish the validity and credibility of the process. 28 The data was processed according to the method set out by the six phases of thematic analysis described by Braun and Clarke. 29 This six phase approach involves: familiarisation with the data through transcription, generating initial codes, searching for themes, reviewing themes, defining and naming themes and producing the final written output. 29 The choice of research design, methodology and theoretical framework, were designed to assist with critical reflection during the research process. Among the program designers and implementation clinicians there was a high desire to see the program reflected in a positive light.
The research team recognised the potential for bias in in the construction of knowledge from the qualitative data. The data were analysed by three of the authors (A.W., J.S.P. and E.D.W.), to ensure the data was interpreted with rigorous research standards J.S.P. and E.D.W. who are experienced qualitative researchers were independent from the design and implementation of the KoSiM program.
The analysis process commenced with familiarisation by reading the transcribed texts several times. The next step involved creating notes and developing preliminary themes via an inductive process performed collaboratively between researchers. These themes were later developed by using a constant comparison technique. 30 From this comparison broad themes were created via journaling and meetings between researchers. Initial categories were created and then broadened to develop hierarchies of concepts and themes. A comprehensive list of codes was developed and reviewed, which was used to analyse the data. The authors debriefed throughout the data analysis process, reflecting on understanding and responses to the quotes, and moved back and forth between the phases. The steps used in the analysis were similar to those outlined by Nowell et al, 28 which aimed to establish rigour and trustworthiness in a thematic analysis. The researchers considered the finalised themes and their supporting quotes, any differences were deliberated on and determined by mutual agreement.

| RESULTS
Of the 103 eligible participants that completed the KoSiM program 75 partook in qualitative interviews about the program. The high level of participation allowed the findings to achieve data adequacy. Participants ranged in age from 24 to 63 years, most participants were female n = 49 (65%). Forty (53%) participants were nurses, 29 (39%) were allied health professionals (psychologist, social worker, occupational therapist) and 6 (8%) were medical staff.
Data analysis revealed four main themes: changes in the approach to working with a lived experience of SMI; changes in attitude to self-care and family wellbeing; observed changes in work culture; and general experiences of the overall program. These themes and their sub-themes are detailed in Table 1. 3.1 | Changes in the approach to working with a lived experience of SMI Participants expressed that engaging in a wellbeing program for themselves had a flow-on effect in terms of the way they approached their It made me think about how difficult it must be for our clients trying to have success with their goals (Male, 43).

Primary themes Sub-themes
Changes in the approach to working with consumers This theme details the changes in the way they approached their practice with mental health consumers to incorporate more physical health.
Increased knowledge: "easier to explain" Enhanced comprehension of physical health care issues and how to manage them in mental health consumers.
Increased confidence: "more assured" The increased belief that participants had in feeling capable to implement physical health initiatives to mental health consumers.
Greater awareness: "difficult for consumers" Greater recognition of the additional challenges consumers' face in managing their physical health.
Role modelling: "practice what you preach" The importance of participants representing the healthy lifestyle they hope to encourage consumers to achieve.
Motivation to change: "not just their mental health" Explores the changes to practice that clinicians made during the intervention.
Changes in attitude to self-care and family wellbeing This theme explains the alterations in approach to their own health and that of their family members.
Self-care: "refocused me" The changes that participants made to their own health during the program.
Healthy families: "flow-on effect" Describes the broader effects of the program on participants families.
Observed changes in work culture This theme explores what changes participants observed in their colleagues and workplace in relation to physical health.
A healthier workplace: "looking out for each other" The impact of the program on the workplace ethos around diet and exercise lifestyle.
Physical health focus: "a real shift in culture" Explores the observed changes in workplace practices incorporating physical health care into the clinical service.
General experiences of the overall program Overall feedback: "It's been wonderful" Details the general feedback on the program as a whole.
Program criticisms: "if there was a refresher" Explores how participants felt the program could be improved.

| Changes in attitude to self-care and family wellbeing
Participants also noted that there were benefits to their own health.
These benefits were an increase in awareness of their own physical health and making lifestyle changes to improve their overall health.
These benefits were also reported to flow on to the participants family members in a similar way to the participants. The program created an increased awareness of physical health issues and with this awareness participants started addressing health issues improving their own self-care and that of their families.
Individual participants stated they made a wide variety of changes to their own self-care that were attributed the program. These  Everyone in the office is talking about their nutrition and exercise goals and that makes us even more motivated.

| Observed changes in work culture
No one is buying unhealthy takeaway anymore (Female, 31).
It was also observed by participants that the culture around discussing the physical health of people with a SMI diagnosis became more prominent. This included seeking advice from colleagues on managing physical health issues in people with whom they worked, physical health issues being discussed at clinical review meetings and the commencement of new groups which target physical health.
The program encouraged some conversations in the workplace about consumers physical activity, diet, and other healthy lifestyle which is really good, and we have not had before. Physical health care now gets included in peoples care plans far more often (Female, 62).
I've noticed the attitude to the physical health of consumers really changed after people did KoSiM. It's been really nice to see clinicians organising new physical activity groups and organising a fruit bowl for the waiting room, there has been a real shift in culture (Male, 47).

| General experiences of the overall program
The overall feedback from participants was very positive and most found the KoSiM program helpful. The program was described as practically-based and personalised to the individual's need.
It was a great opportunity that I've really valued, and I It would have been great to do some group sessions to work with others. I guess with the diet aspect the one on one has been very useful and I did not require a practical  21 This quantitatively demonstrates that there was no reduction in the achieved changes of attitudes, confidence and knowledge of metabolic health, and no increase to perceived barriers to implementing metabolic initiatives, 3 months after completing the intervention.
The cultural aspects of an organisation must be purposefully moulded; as they are a vital factor on which improvement focused change such as incorporation of physical health care into mental health services is facilitated. 37 Short-term organisational culture change has been observed in this study, via, visible manifestations, shared ways of thinking and deeper shared assumptions. To achieve longer-term practice change in this area it will require authentic participation from staff to promote the prevailing shape of feeling, thinking, discussing and accomplishing that underpin metabolic health practice. 38 Maintenance of this culture can not exist without strong leadership from the wider organisation to continue supporting metabolic health care as a priority. 39 Improved clinical practices such as implementing physical health care within mental health services are essential to meet the shifting demands of health care, however, implementing these initiatives can be challenging. The sheer number of changes and the pace of change lead to what is often referred to as change fatigue. 40 The KoSiM program offers a novel approach for achieving change through offering a service to the staff ultimately tasked with delivering screening and intervention of a similar initiative to people they are working with.
Training staff through this approach may achieve greater "buy-in" in a shorter time frame for what is a priority area of mental health reform. 41

| LIMITATIONS
Data for this study was collected in 2015 and 2016 within a week of each participant completing their five-week intervention. Ideally, this data would have been published in a timelier manner, however, it was held back awaiting publication of the primary quantitative article and then delays from the COVID pandemic. Despite the publication delay the data was analysed within 6 months of the completion of data collection, and we believe remains of high relevance.
This study was subject to several methodological limitations.
Although the primary aim was to understand the experiences of participants who completed the program, there are aspects to the KoSiM program that cannot be explored by only interviewing those who successfully completed the intervention. The study missed the opportunity to understand why participants may have dropped out of the intervention or why they chose to not take up the opportunity to participate. To draw conclusions as to the success of the program without considering those who dropped out is unwarranted. By drawing a sample group that caters for maximum variation, it would provide a fairer representation of the entire local mental health workforce. 42 This information could provide further insights as to whether the KoSiM program is a viable method of implementing physical health care in mental health services more generally.
Another limitation is the potential for bias as interviewers were members of the intervention team. This can lead to problems in two ways, first, participants may feel more inclined to tell the interviewer what they want to hear rather than their true reflections on the program. Secondly, the interviewer is a co-creator of the data and as such could introduce bias into the questioning process. 43 Interviewers helped mitigate the issue of instigator bias by using a reflective process and carefully structured non-leading questions.

| CONCLUSION
The current study enhances the understanding of offering an indivi-